Psychiatric Emergency Department Visits in California, Session: Spatial Analysis, Paper # 1245

Transcription

1 Psychiatric Emergency Department Visits in California, Session: Spatial Analysis, Paper # 1245 Esri User s Conference San Diego, CA July 15, 2014

2 Participants»Jim E. Banta, PhD, MPH»Mark G. Haviland, PhD (School of Medicine, Psychiatry)»Nicole M. Gatto, PhD»Sam Soret, PhD»Ed Santos, MCSD

3 Background Why are psychiatric Emergency Department (ED) visits of interest?

4 Psychiatric ED visits often reflect inaccessible or unavailable psychiatric or primary-care options. 1 They are increasing more rapidly than general ED visits, 1 and accounted for an estimated 4.5 million ED visits nationally in They often lead to suboptimal treatment outcomes CDC. MMWR. 2013;62(23): CDC. Table nhamcs_emergency/2010_ed_web_tables.pdf. 3. Korn, et al. The Journal of Emergency Medicine. 2000;18(2):

5 Psychiatric ED visits impose substantial economic burden on healthcare system. 1 A study in North Carolina found psychiatric ED visits twice as likely to result in hospital admission compared to all other ED visits. 2 Higher psychiatric inpatient rates often found in areas with greater poverty and a greater concentration of ethnic minorities, particularly African Americans. 3 Mental Health Services Act 1. Schneider, et al. Annals of Emergency Medicine. 2003;42(2): CDC. MMWR. 2013;62(23): Almog, et al. Social Science & Medicine. 2004;59(2):

6 Research Question: Within California are there area-based differences in psychiatric ED visits and subsequent hospitalizations (if yes, one could better identify where to expand outpatient treatment)

7 Method Secondary data analysis using administrative data and government-defined diagnostic coding scheme.

8 Data: Public-Use ED visit files from Office of Statewide Heath Planning and Development: All ED visits from community-based hospitals in California (348 with ED visits). - Patient ZIP Code smallest level of geography. (1,669 valid ZIP Codes for analysis) - Some demographic data is masked.

9 Psychiatric visits defined using 14 CCS categories: - Larger unit of area measure Dartmouth Atlas Hospital Referral Regions (28 for California), available at: - 2f7f9c38a Hospital locations: -

10 Software: - ArcGIS for Desktop - SAS 9.3 for Windows Analysis: - Descriptives using SAS - Mapping ED hospitalization rates by Hospital Referral Region - Logistic regression for ED visits resulting in hospitalization - Mapping significant ZIP Codes

11 Results During study period: 60.6 million ED visits 2.6 million of these had primary psychiatric diagnosis 2.53 million of these had good ZIP Code data

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13 California Psychiatric ED Visits ( ) Disposition N=2,531,811 Discharged to home or self-care (routine) 78.6 Hospitalized 17.9 Left against medical advice 2.3 Other 1.3 TOTAL: 100.0

14 Hospitalization Type N=452,120 Discharged/Transferred (D/T) to a psychiatric hospital or psychiatric distinct part unit of a hospital D/T to a short-term general hospital for inpatient care D/T to a designated cancer center or children s hospital 9.67 D/T to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part unit of a 0.66 hospital D/T to a Medicare certified long-term care hospital (LTCH) 0.23 D/T to a critical access hospital (CAH) 0.06 D/T to a hospital-based Medicare approved swing bed 0.01

15 Clinical Classifications Software (CCS) Categories All mental N= 2,531,811 % of category hospitalized 651 Anxiety disorders Alcohol-related disorders Mood disorders Schizophrenia and other psychotic disorders Suicide and intentional self-inflicted injury Substance-related disorders Miscellaneous disorders; Screening and history of mental health and substance abuse codes

16 Clinical Classifications Software (CCS) Categories All mental N= 2,531,811 % of category hospitalized 662 Suicide and intentional selfinflicted injury Schizophrenia and other psychotic disorders Screening & history of mental health and substance abuse codes Mood disorders Impulse control disorders, NEC Personality disorders Attention-deficit, conduct, and disruptive behavior disorders Developmental disorders Overall Average 17.9

17 Hospital Referral Region % of Census 2010 % of mental visits % visits hospitalized Los Angeles San Diego San Bernardino Sacramento Orange County San Francisco San Jose Alameda County Fresno Contra Costa County Bakersfield Modesto Ventura

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19 All Mental N=2,531,811 % of category hospitalized Gender Male Female Masked Age 1 to to to plus Masked

20 All Mental N=2,531,811 % of category hospitalized Race / ethnicity Hispanic Asian Black White Other race Masked race Payer Source Self-pay Medicaid Medicare Other Private insurance

21 Receiver Operator Curve analysis. 1 Based on Logistic regression, where 0=not hospitalized, 1=hospitalized (N= 2,182,796 ). AUROC % explained variation No variables Year only Adding demographics Adding insurance Adding diagnosis Adding patient ZIP Code Adding Hospital ID Banta, et al. Critical Care Medicine. 2012;40(11):

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23 Conclusion Within California, there is areabased variation in psychiatric ED visits and subsequent hospitalizations.

24 There is modest spatial variation in populationbased rates of psychiatric ED visits. There is more dramatic spatial variation in the percentage of psychiatric ED visits resulting in hospitalization. There are some similarities in these findings to earlier spatial analyses of psychiatric hospitalizations in California. 1 Some of the spatial differences in percentage of hospitalizations is due to socio-demographics. 1. Banta, et al. The Journal of Behavioral Health Services & Research. 2008;35(2):

25 Limitations Administrative data Masked/missing demographics Using visits, not persons ZIP Codes as unit of geography.

26 Future Directions Sub-group analyses based on demographics / diagnosis. Use other area-based measures of socio-demographics, such as Tapestry. Cluster analysis vs. spatial regression.